CE article: Good Catch program encourages near-miss reporting*

Good Catch program at Texas organization encourages near-miss reporting

Staff members are often trained to report a potential medical error, or near-miss event. However, more often than not, these events go unreported. In 2003, The University of Texas (UT) System, made up of six health institutions, developed a system that allowed the anonymous reporting of close calls, near misses, and potential errors.

Despite the reports’ anonymity, only 175 events were reported during the first two-and-a-half years of the program.

After seeing this result, Robert L. Massey, PhD, RN, NEA-BC, director of clinical nursing at UT’s M. D. Anderson Cancer Center, and a former colleague wanted to know why the program was not working and how they could encourage staff to report medical errors.

In 2005, Massey and his former colleague proposed and implemented a pilot test of the Good Catch program at M. D. Anderson. By putting a positive spin on the reports (emphasizing that increased reporting of near misses helps the hospital learn how to prevent future errors) and developing a competition to encourage reporting, M. D. Anderson received 2,744 reports of potential errors during the initial six months of the pilot program.

A positive twist on reporting medical errors

The Good Catch program’s pilot test began in December 2005 and ran through May 2006. Three components make up the program and help it stand out from the previous program used by the organization:

Terminology change

End-of-shift safety reports

Incentives, such as safety awards, which are supported by executive leadership

M. D. Anderson’s original reporting system used the terms “near miss” or “close call” to report potential errors.

“The phrases ‘near miss’ and ‘close call’ came across to the staff as almost negative,” says Massey. After taking a close look at the terminology, M. D. Anderson chose to use the phrase “good catch” to identify when a potential error is reported.

“Using ‘good catch’ takes a more positive connotation, and staff members are not as discouraged to report potential errors,” says Massey. “These types of events never get to the patient, or else they would not be considered a good catch.”

In addition to changing the terminology, M. D. Anderson decided to encourage staff members to report these potential errors at the end of their shifts through an end-of-shift safety report. The communication encourages staff coming off shift to talk with the staff coming on shift about any good catches that occurred throughout the shift. Doing so helps all staff members maintain awareness about potential errors for which to be on the lookout.

For example, if a staff member on the morning shift reports a transcription order error, the next staff member coming on shift is made aware of the situation so he or she can be mindful of a potential good catch of the same nature.

“If this happens multiple times on a shift or in a 24-hour period, we can address the situation immediately,” says Massey.

Friendly competition among staff is also used to encourage the submission of good catches at M. D. Anderson. The organization uses a baseball theme as a form of competition, says Massey. Inpatient units form teams—complete with mascots created by each team—and the team that reports the most good catches at the end of each “season” wins.

“We follow the same schedule as the regular baseball season,” says Massey. “And around October, we hold a ‘World Series’ for the two teams in each league that have the most good catches up to that point.”

Throughout the year, teams receive safety awards for submitting the most good-catch reports. The teams are also part of divisions, each of which hosts its own divisional playoffs for the most good-catch reports.

Eventually, the teams with the most good-catch reports in each division are eligible for the World Series. Both teams then compete for the championship. Massey and his staff monitor any increase in reporting greater than 10% to make sure there is no padding of results.

At the conclusion of the World Series, the winning team receives a safety award party—usually a pizza and cake party. The team also gets a trophy.

“We wanted to encourage the staff to get creative with the baseball league and have fun while doing this,” says Massey.

To keep track of each good catch, the team members anonymously submit their reports through the facility’s online error reporting system, using a team-specific entry code. The system also keeps a running record of every good catch that is reported, and Massey and a performance improvement team review these to make sure good catches are not reported twice.

Within the first month of the pilot program, M. D. Anderson’s staff recorded 1,000 good catches, Massey says. After that, 3,000–4,000 reports were recorded per month.

Each documented good catch requires an inquiry into its near occurrence. Massey looks further into the details surrounding each good catch to see whether the report points to a better way to carry out a process.

“Review of the reported good catches during the pilot and after program implementation revealed that one of the biggest problem areas for us was medications,” says Massey.

Approximately 60% of good-catch reports involved medications, he says.

For example, Massey discovered that many reports resulted from missing medications. This was most common upon a patient’s admission, when staff members would have to wait for the pharmacy to get the patient the correct medication. After noticing this, Massey, unit staff, and pharmacy staff established a list of the most common medications needed at admission. Now staff members no longer have to wait, and the pharmacy has these specific medications at the ready.

The Good Catch program also helped M. D. Anderson identify old equipment that was not working correctly and needed to be replaced. The facility’s epidural pumps were an example of equipment identified in this manner, and in 2008, it implemented the use of a new epidural pump.

Upper management buy-in

Management helps facilitate the Good Catch program and is a key driver in its success, says Massey. Barbara Summers, PhD, RN, chief nursing officer, makes rounds on each unit and hands out pins to those participating in the baseball league.

“She has, and continues to be, our most active supporter of the program,” says Massey. “She is present for all safety award ceremonies.”

What initially started as an anonymous six-month pilot program is now something more. Employees are less afraid to report a potential error now that they report the location where the good catch occurred, says Massey.

“The staff is real happy and proud that they are making the patient safer and, in turn, helping improve patient safety at M. D. Anderson,” he says.

In addition to seeing improved near-miss reporting, M. D. Anderson has witnessed a reduction in patient falls, transcription errors, and the distribution delay of infusion devices. Good Catch data allow the facility to redesign processes based on the knowledge of areas where they have broken down in the past.

Next up for the hospital is implementation of a complete electronic reporting system, which will help improve the way the catches are recorded and tracked.